Morbidity and Mortality Weekly Report
Fatal Occupational Asthma in Cannabis Production — Massachusetts, 2022
Virginia M. Weaver, MD1; Jeremy T. Hua, MD2; Kathleen M. Fitzsimmons, PhD3; James R. Laing3; Wigdan Farah, MBBS4; Anne Hart5;
Trapper J. Braegger6; Michelle Reid, MPH3; David N. Weissman, MD7
Abstract
Multiple respiratory hazards have been identified in the
cannabis cultivation and production industry, in which
occupational asthma and work-related exacerbation of
preexisting asthma have been reported. An employee work-
ing in a Massachusetts cannabis cultivation and processing
facility experienced progressively worsening work-associated
respiratory symptoms, which culminated in a fatal asthma
attack in January 2022. This report represents findings of an
Occupational Safety and Health Administration inspection,
which included a worksite exposure assessment, coworker and
next-of-kin interviews, medical record reviews, and collabora-
tion with the Massachusetts Department of Public Health.
Respiratory tract or skin symptoms were reported by four
of 10 coworkers with similar job duties. Prevention is best
achieved through a multifaceted approach, including control-
ling asthmagen exposures, such as cannabis dust, providing
worker training, and conducting medical monitoring for
occupational allergy. Evaluation of workers with new-onset or
worsening asthma is essential, along with prompt diagnosis and
medical management, which might include cessation of work
and workers’ compensation when relation to work exposures
is identified. It is important to recognize that work in cannabis
production is potentially causative.
Introduction
Studies in the cannabis cultivation and production industry
have identified multiple respiratory hazards such as microbial
and plant allergens and irritants, as well as chemicals, includ-
ing pesticides, and allergens specific to the cannabis plant itself
(1–3). Employees in some work areas are exposed to large
quantities of ground cannabis. Respiratory and skin signs and
symptoms, including asthma, allergic rhinitis, and urticaria,
have been reported (2,3). Work-related asthma includes occu-
pational asthma (new-onset asthma induced by sensitizers or
irritants) and work-related exacerbation of preexisting asthma,
worsened by work exposures (4). An employee working in a
Massachusetts indoor cannabis facility experienced progres-
sively worsening work-associated respiratory symptoms, which
culminated in a fatal occupational asthma attack. This report
provides information obtained in the public health investiga-
tion performed to determine the cause of this fatality and
identify prevention options.
1257
US Department of Health and Human Services | Centers for Disease Control and Prevention | MMWR | November 17, 2023 | Vol. 72 | No. 46
Case Report
The employee, a woman aged 27 years, began work at an
indoor cannabis cultivation and processing facility on May 20,
2021. She worked throughout the facility as a cycle counter,
including in areas where the cannabis product was ground
(Figure). In late July, she experienced onset of nausea, loss of
taste and smell, earache, and cough, and her employer required
her to obtain SARS-CoV-2 testing; the results of two tests were
negative. Bilateral diffuse wheezing was noted when a physi-
cal examination was performed during the evaluation for the
second test. The patient’s mother later reported that, although
her daughter had no previous history of asthma, allergies, or
skin rash, she had developed work-related runny nose, cough,
and shortness of breath after 3–4 months of employment.
On October 1, the employee moved to flower production,
which entailed grinding of cannabis flowers for approximately
15 minutes, three times per day, and preparing cannabis ciga-
rettes (prerolls). These activities resulted in increased dust expo-
sure. Dust from the grinder was collected by a shop vacuum;
however, the vacuum had no high-efficiency particulate air
(HEPA) filter, and visible dust escaped. Additional dust-gen-
erating processes included open handling of ground product
(e.g., while transferring product from the grinder and filling
prerolls). Other flower production coworkers reported that the
employee’s cough increased, particularly when the grinder was
on. Efforts to reduce her exposure included covering the grinder
vacuum with plastic (the outside of which became visibly coated
with ground cannabis) and moving her workstation outside the
grinder room. She also used her own N95 respirator and wore
company-required long sleeves and gloves while working.
On November 9, the employee became acutely dyspneic
at work and was transported by emergency medical services
(EMS) to a local emergency department (Figure). Enroute to
the hospital, she received an albuterol nebulizer, and her dys-
pnea resolved. She reported that she did not have asthma but
stated that she might be allergic to something at work because
she had had a cough and runny nose for >1 month. Bilateral
faint wheezes were noted, and she was prescribed a 5-day course
of prednisone, cetirizine, and an albuterol inhaler; follow-up
with a primary care physician was recommended. Her mother
reported that the employee did not become short of breath at
home, except when carrying a heavy load upstairs. She said
that her daughter told her before her subsequent fatal asthma
attack that the inhaler, which she used primarily at work, was
 Morbidity and Mortality Weekly Report

FIGURE. Timeline of work assignments,* onset of signs and symptoms, and events associated with fatal occupational asthma in a cannabis
facility worker — Massachusetts, 2021–2022
h Options
ide = 7.5”
tats = 5.0” Nov 9, 2021
ns = 4.65” Transported from work to
mn = 3.57” ED for dyspnea;
scattered faint bilateral
wheezes;
Jan 2016 SARS-CoV-2 test result
Pulmonary Jul–Aug 2021 negative; normal CXR
evaluation for Nausea, loss of taste Sep–Oct 2021 Jan 4, 2022
chronic cough; and smell, earache, Onset of work- Onset of status asthmaticus
asthma excluded cough, and associated rhinitis, at work, leading to
(normal pre- and wheezing; cough, and dyspnea cardiopulmonary arrest
postbronchodilator negative SARS-CoV-2 reported by patient’s and ICU admission;
spirometry) PCR test result (twice); mother and anoxic brain injury resulted
normal CXR coworkers in death

May 20–Sep 30, 2021 Oct 1, 2021–Jan 4, 2022

Cycle counter Flower technician

May Jun Jul Aug Sep Oct Nov Dec Jan

2021 2022
Month and year

Abbreviations: CXR = chest radiograph; ED = emergency department; ICU = intensive care unit; PCR = polymerase chain reaction.
* Cycle counter’s responsibilities are counting packaged cannabis products throughout the facility, including in ground product areas; flower technician’s responsibilities
are grinding cannabis flowers and making prerolls.

nearly empty. This finding suggests that the employee had
used most of the approximately 200 inhalations available in
her inhaler over a period of approximately 2 months.
On January 4, 2022, the employee told a coworker that her
shortness of breath had been getting progressively worse during
the preceding 2 weeks. Later that day, while filling prerolls,
she began sneezing, and her coughing increased. Despite
repeated albuterol inhaler use, her dyspnea worsened, and
EMS was called again. She suffered a cardiopulmonary arrest
before EMS arrived, and her coworkers began resuscitation.
She regained spontaneous circulation. However, she did not
regain consciousness. Expiratory wheezing was noted. Anoxic
brain death was diagnosed on January 7, 2022, and care was
withdrawn. An autopsy was not performed.
Public Health Investigation
The Massachusetts Department of Public Health inves-
tigation revealed that the employee had had a pulmonary
evaluation in 2016 for chronic cough, which included pre-
and postbronchodilator spirometry without a methacholine
challenge (a bronchoprovocation test used to help diagnose
2015, and subsequently had not prescribed any allergy or
asthma medication.
The Occupational Safety and Health Administration
(OSHA) inspection included personal air sampling after the
grinder was connected to a new shop vacuum with HEPA
filtration. The 8-hour time-weighted average respirable dust
concentration in air from the personal breathing zone of
the grinder operator was 0.012 mg/m3, and for two nearby
employees, was nondetectable; OSHA’s permissible exposure
limit for respirable dust (particulates not otherwise regulated)
is 5 mg/m3.* Additional 8-hour monitoring for endotoxin, a
pro-inflammatory contaminant associated with gram-negative
bacterial growth on organic materials such as cannabis flowers,
revealed 27 endotoxin units per cubic meter of air (EU/m3)
(grinder operator) and 1.8 and 1.9 EU/m3 (nearby employees);
the Dutch Expert Committee on Occupational Safety 8-hour
time weighted average recommendation is ≤90 EU/m3.† A
15-minute personal air sample obtained from the personal
* https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.100
0TABLEZ1
† A recommended short-term exposure limit for endotoxins has not been

asthma). The pulmonologist excluded asthma and implicated
cigarette and marijuana smoking, gastroesophageal reflux
disease, and rhinitis in the etiology of her cough symptoms.
Her primary care physician had not seen the employee since
established. Importantly, airborne respirable dust and endotoxin levels below
occupational exposure limits do not exclude work-related triggers of asthma
and other allergic signs and symptoms (e.g., cannabis allergens). https://www.
healthcouncil.nl/documents/advisory-reports/2010/07/15/
endotoxins-health-based-recommended-occupational-exposure-limit

1258
US Department of Health and Human Services | Centers for Disease Control and Prevention | MMWR | November 17, 2023 | Vol. 72 | No. 46
 Morbidity and Mortality Weekly Report
breathing zone of the operator during active grinding was
14 EU/m3. OSHA interviewed one former and nine cur-
rent flower production coworkers of the employee during
February–April, 2022, four of whom reported work-related
respiratory tract or skin signs and symptoms; symptoms in
the former employee suggested occupational asthma, because,
although he had a past history of asthma, he had not required
a bronchodilator inhaler since adolescence. This activity was
reviewed by CDC, deemed not research, and was conducted
consistent with applicable federal law and CDC policy.§
Discussion
Cannabis industry employees are exposed to large quantities
of ground product in some work areas, such as flower grinding
and preroll production. Asthma, allergic rhinitis, and urticaria
have been reported among cannabis production workers (2,3).
Several allergens have been identified, and irritants are pres-
ent as well (1–3). Work-related asthma includes occupational
asthma (i.e., new-onset asthma induced by sensitizers or irri-
tants) and work-exacerbated asthma (i.e., preexisting asthma
worsened by work exposures) (4). In this case, absence of a
history of asthma and the temporal relationship between work
exposure and asthma signs and symptoms are consistent with
a diagnosis of occupational asthma. Airborne respirable dust
and endotoxin levels below occupational exposure limits do
not exclude a sufficient level of airborne allergen to trigger
asthma and other allergic symptoms.
Enhanced surveillance for work-related asthma in the state
of Washington identified seven asthma cases among employees
in indoor cannabis production facilities (5). Three employees
with work-exacerbated asthma discontinued cannabis employ-
ment; one with occupational asthma was symptomatic in two
different cannabis facilities separated by a 2-year asymptomatic
period while unexposed.
In a study of employees at an indoor Washington cannabis
production facility, 13 of 31 employees had symptoms sugges-
tive of asthma (i.e., presence of either an attack of shortness of
breath, an attack of asthma, or the use of asthma medication)
(6). Among 10 employees with occupational allergy symp-
toms, seven had abnormal spirometry, and five had skin prick
testing consistent with cannabis sensitization. Five employees
had abnormal or borderline fractional exhaled nitrogen oxide
testing, which is used as a marker of airway inflammation in
asthma management; results increased significantly across the
work week, indicating an increase in airway inflammation.
Fatal asthma can occur even with disease that is considered
mild; disparities in income, education, and access to health
care are risk factors associated with death (7). Work-related
§ 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C.
Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
1259
US Department of Health and Human Services | Centers for Disease Control and Prevention | MMWR | November 17, 2023 | Vol. 72 | No. 46
asthma has also been associated with poorer asthma control (8).
Additional risk factors for the deceased employee in this case
report include the emergency department visit, recent use of oral
glucocorticoids, increased dyspnea and bronchodilator inhaler
use without inhaled glucocorticoids, continued exposure, and
lack of a provider with expertise in occupational allergies (7,9).
Occupational asthma is generally associated with a latency
period of months to years between first exposure and symptoms
(10). For example, fatal occupational asthma related to exposure
to powdered shark cartilage was reported 16 months after expo-
sure onset (10). Although latency from this employee’s first occu-
pational cannabis exposure to symptom onset was short, latency
from first exposure was longer because of personal cannabis use.
Cross-sensitivity between cannabis and plant allergens might also
have predisposed this employee to cannabis sensitization (3).
Limitations
The findings in this report are subject to at least three limita-
tions. First, although the employee’s course is consistent with
fatal asthma triggered by cannabis allergy, this finding was not
evaluated by skin testing or specific immunoglobulin E tests.
Second, airborne cannabis allergen levels could not be assessed.
Finally, as in many occupational fatality cases, investigators
were not able to speak with the employee, requiring details to
be obtained from other sources such as medical records and
interviews with coworkers and next-of-kin.
Implications for Public Health Practice
Providers and public health professionals would benefit from
additional research into prevalence and risk factors for cannabis-
related occupational allergies. Development and implementation
of strategies to protect workers are critical in this rapidly expanding
industry. Measures to protect employees might include determina-
tion and control of exposures, training of employees and facility
managers, correct use of personal protective equipment, and
medical management of employees with work-related symptoms,
which might require cessation of work and workers’ compensation
(Box). It is important to recognize that work in cannabis produc-
tion is a risk for occupational allergies.
Corresponding author: Virginia M. Weaver, weaver.virginia.m@dol.gov.
1Office of Occupational Medicine and Nursing, Directorate of Technical
Support and Emergency Management, Occupational Safety and Health
Administration, U.S. Department of Labor, Washington, DC; 2Division of
Environmental & Occupational Health Sciences, National Jewish Health,
Denver, Colorado; 3Occupational Health Surveillance Program, Massachusetts
Department of Public Health; 4Division of Pulmonary and Critical Care
Medicine, Mayo Clinic, Rochester, Minnesota; 5Region 1, Occupational Safety
and Health Administration, U.S. Department of Labor, Springfield,
Massachusetts; 6Salt Lake Technical Center, Directorate of Technical Support
and Emergency Management, Occupational Safety and Health Administration,
U.S. Department of Labor, Salt Lake City, Utah; 7Respiratory Health Division,
National Institute for Occupational Safety and Health, CDC.
 Morbidity and Mortality Weekly Report
BOX. Measures for protecting cannabis industry employees from occupational hazards — United States, 2023
Exposure Assessment*,†
• Qualitative assessment to identify areas and processes of
highest potential dust exposure
• Quantitative assessment of airborne levels as needed to
assist in evaluating controls for dust and other exposures
Environmental Exposure Controls
• Equipment controls (e.g., exhaust ventilation for cannabis
grinder) to mitigate risk from dust-producing processes
• Work procedures to reduce airborne dust (e.g., high-
efficiency particulate air–filtered vacuuming rather than
dry sweeping)
Personal Protective Equipment
• In dusty settings, personal protective equipment for skin
(e.g., gloves, long sleeves, or sleeve guards), eyes (e.g.,
safety glasses or goggles) and respiratory protection (e.g.,
an N95 particulate respirator) as needed
• However, personal protective equipment might not be
effective for persons with signs and symptoms of work-
related allergies
Employee Training
• To identify potential job hazards
• To recognize signs and symptoms of occupational allergy
(e.g., rhinitis, conjunctivitis, asthma, and urticaria;
particularly if new-onset or worse at work)
• To seek prompt medical evaluation for signs and
symptoms of occupational allergy
* https://stacks.cdc.gov/view/cdc/91903
† https://www.researchgate.net/publication/369800248_
The_Emerging_Spectrum_of_Respiratory_Diseases_in_the_US_Cannabis_Industry
Summary
What is already known about this topic?
Occupational allergic diseases, including asthma, are an emerg-
ing concern in the rapidly expanding U.S. cannabis industry.
What is added by this report?
In 2022, the first death attributed to occupational asthma in a
U.S. cannabis production worker occurred in Massachusetts.
This case illustrates missed opportunities for prevention,
including control of workplace exposures, medical surveillance,
and treatment according to current asthma guidelines.
What are the implications for public health practice?
Prevention is best achieved through a multifaceted approach. It
is essential to evaluate workers with new-onset or worsening
asthma for relation to work exposures and to recognize work in
cannabis production as potentially causative.
1260
US Department of Health and Human Services | Centers for Disease Control and Prevention | MMWR | November 17, 2023 | Vol. 72 | No. 46
• To use work processes that minimize exposures*
• To use and maintain personal protective equipment
Medical Surveillance
• Directed by a health care provider with expertise in
occupational allergy and asthma
• Focused on early detection of signs and symptoms of
occupational allergy
• Aggregated analysis of all workers’ results to identify
exposures and jobs that result in highest risk for allergic
sensitization and disease
Medical Management Options and Workers’ Compensation
• Workplace restrictions for sensitized persons, recognizing
that complete cessation of exposure rather than exposure
reduction might be necessary
• Recognition of work-related allergic sensitization
potential in cannabis industry employees for workers’
compensation claims and regulations
Examples of Current Research Gaps
• Development of exposure assessment methods and
exposure controls to facilitate effective prevention of
occupational allergic disease
• Assessment of prevalence and risk factors for occupational
allergy and disease in cannabis workers
• Development of reliable, clinically available diagnostic
tests for cannabis sensitization
All authors have completed and submitted the International
Committee of Medical Journal Editors form for disclosure of
potential conflicts of interest. Jeremy T. Hua reports support from the
Reuben M. Cherniack fellowship award at National Jewish Health.
Wigdan Farah reports support from the Mayo Clinic. Trapper J.
Braegger and Anne Hart report support from the Occupational
Safety and Health Administration. James R. Laing reports support
from the U.S. Department of Labor’s Bureau of Labor Statistics
for documentation of workplace fatalities for the Census of Fatal
Occupational Injuries, unrelated to the current work. No other
potential conflicts of interest were disclosed.
References
1. Couch JR, Grimes GR, Green BJ, Wiegand DM, King B, Methner MM.
Review of NIOSH cannabis-related health hazard evaluations and
research. Ann Work Expo Health 2020;64:693–704. PMID:32053725
https://doi.org/10.1093/annweh/wxaa013
 Morbidity and Mortality Weekly Report
2. Decuyper II, Green BJ, Sussman GL, et al. Occupational allergies to
cannabis. J Allergy Clin Immunol Pract 2020;8:3331–8. PMID:33161961
https://doi.org/10.1016/j.jaip.2020.09.003
3. Sack C, Simpson C, Pacheco K. The emerging spectrum of
respiratory diseases in the U.S. cannabis industry. Semin Respir
Crit Care Med 2023;44:405–14. PMID:37015286 https://doi.
org/10.1055/s-0043-1766116
4. Tarlo SM, Balmes J, Balkissoon R, et al. Diagnosis and management of
work-related asthma: American College of Chest Physicians consensus
statement. Chest 2008;134(Suppl):1S–41S. PMID:18779187 https://
doi.org/10.1378/chest.08-0201
5. Reeb-Whitaker C, LaSee CR, Bonauto DK. Surveillance of work-related
asthma including the emergence of a cannabis-associated case series in
Washington state. J Asthma 2022;59:1537–47. PMID:34288786 https://
doi.org/10.1080/02770903.2021.1955379
6. Sack C, Ghodsian N, Jansen K, Silvey B, Simpson CD. Allergic and
respiratory symptoms in employees of indoor Cannabis grow facilities.
Ann Work Expo Health 2020;64:754–64. PMID:32459852 https://doi.
org/10.1093/annweh/wxaa050
1261
US Department of Health and Human Services | Centers for Disease Control and Prevention | MMWR | November 17, 2023 | Vol. 72 | No. 46
7. Madison JM, Irwin RS. Identifying patients at risk for fatal asthma.
Waltham, MA: UpToDate; 2023. Accessed April 7, 2023. https://www.
uptodate.com/contents/identifying-patients-at-risk-for-fatal-asthma
8. Mazurek JM, Henneberger PK. Use of population data for assessing
trends in work-related asthma mortality. Curr Opin Allergy Clin
Immunol 2019;19:98–104. PMID:30601151 https://doi.org/10.1097/
ACI.0000000000000508
9. National Heart, Lung, and Blood Institute. Expert panel report 3:
guidelines for the diagnosis and management of asthma. Bethesda, MD:
US Department of Health and Human Services, National Institutes of
Health; 2007. https://www.nhlbi.nih.gov/sites/default/files/media/docs/
EPR-3_Asthma_Full_Report_2007.pdf
10. Ortega HG, Kreiss K, Schill DP, Weissman DN. Fatal asthma from
powdering shark cartilage and review of fatal occupational asthma
literature. Am J Ind Med 2002;42:50–4. PMID:12111690 https://doi.
org/10.1002/ajim.10088